Neuromuscular Consequences of Anterior Cruciate Ligament Injury

Ingersoll, Christopher D.; Grindstaff, Terry L.; Pietrosimone, Brian; Hart, Joseph M.

doi:10.1016/j.csm.2008.03.004

Cited by 203 publications

(185 citation statements)

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“…1,17,45,46 Persistent asymmetry in quadriceps strength and activation driven by the involved limb after ACLR may increase the likelihood of poor functional outcomes, reinjury, and longterm joint degeneration. 13,[47][48][49] Investigators 4,14,22,38,50-52 largely have focused on strength-based measures and more functional movement patterns without describing the symmetry of cortical and spinal measures of quadriceps function. Our findings confirm the presence of quadriceps strength and activation asymmetry well past the point of return to activity in a fairly young and active population with uncomplicated ACLR (Table 3).…”

Section: Discussionmentioning

confidence: 99%

“…[10][11][12] These techniques allow researchers and clinicians to measure the peripheral and central sources of persistent quadriceps dysfunction. [10][11][12][13] Reductions in quadriceps strength, 10,14 quadriceps activation, 10,14 and cortical drive to the quadriceps 11 have been shown months to years after ACLR. Despite these reports, clinically assessing and detecting quadriceps dysfunction during the terminal phases of rehabilitation remains difficult due to the often subtle reductions in strength and activation.…”

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confidence: 99%

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Persistent Neuromuscular and Corticomotor Quadriceps Asymmetry After Anterior Cruciate Ligament Reconstruction

Kuenze

Hertel

Weltman

et al. 2015

Journal of Athletic Training

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104

116

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Context: Return to activity in the presence of quadriceps dysfunction may predispose individuals with anterior cruciate ligament reconstruction (ACLR) to long-term joint degeneration. Asymmetry may manifest during movement and result in altered knee-joint-loading patterns; however, the underlying neurophysiologic mechanisms remain unclear.Objective: To compare limb symmetry of quadriceps neuromuscular function between participants with ACLR and participants serving as healthy controls.Design: Descriptive laboratory study. Setting: Research laboratory. Patients or Other Participants: A total of 22 individuals with ACLR (12 men, 10 women) and 24 individuals serving as healthy controls (12 men, 12 women).Main Outcome Measure(s): Normalized knee-extension maximal voluntary isometric contraction (MVIC) torque (Nm/ kg), quadriceps central activation ratio (CAR) (%), quadriceps motor-neuron-pool excitability (Hoffmann reflex to motor wave ratio), and quadriceps active motor threshold (AMT) (% 2.0 T) were measured bilaterally and used to calculate limb symmetry indices for comparison between groups. We used analyses of variance to compare quadriceps Hoffmann reflex to motor wave ratio, normalized knee-extension MVIC torque, quadriceps CAR, and quadriceps AMT between groups and limbs.Results: The ACLR group exhibited greater asymmetry in knee-extension MVIC torque (ACLR group ¼ 0.85 6 0.21, healthy group ¼ 0.97 6 0.14; t 44 ¼ 2.26, P ¼ .03), quadriceps CAR (ACLR group ¼ 0.94 6 0.11, healthy group ¼ 1.00 6 0.08; t 44 ¼ 2.22, P ¼ .04), and quadriceps AMT (ACLR group ¼ 1.13 6 0.18, healthy group ¼ 1.02 6 0.11; t 34 ¼À2.46, P ¼ .04) than the healthy control group.Conclusions: Asymmetries in measures of quadriceps function and cortical excitability were present in patients with ACLR. Asymmetry in quadriceps strength, activation, and cortical excitability persisted in individuals with ACLR beyond return to recreational activity. Measuring the magnitude of asymmetry after ACLR represents an important step in understanding long-term reductions in self-reported function and increased rate of subsequent joint injury in otherwise healthy, active individuals after ACLR.Key Words: quadriceps activation, limb symmetry index, transcranial magnetic stimulation Key PointsThe anterior cruciate ligament reconstruction (ACLR) group exhibited a weaker, less activated quadriceps and less cortical excitability in the reconstructed limb than in the contralateral limb and in the limbs of the healthy control group. Asymmetry in quadriceps strength, activation, and cortical excitability persisted in individuals with ACLR beyond return to recreational activity. Chronic asymmetry indicated reduced dynamic force absorption at the knee and may explain the increased rate of knee reinjury and chronic joint degeneration after ACLR.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Persistent Neuromuscular and Corticomotor Quadriceps Asymmetry After Anterior Cruciate Ligament Reconstruction

Kuenze

Hertel

Weltman

et al. 2015

Journal of Athletic Training

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104

116

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“…P ersistent quadriceps weakness after knee injury or surgery is frequently reported in the literature. 1,2 Quadriceps strength and endurance are of vital importance for normal knee joint function, so restoring normal quadriceps function after knee joint injuries is an essential component of rehabilitation. Persistent posttraumatic quadriceps weakness presents a difficult clinical dilemma for the treating clinician.…”

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confidence: 99%

Quadriceps Activation Following Knee Injuries: A Systematic Review

Hart

Pietrosimone

Hertel

et al. 2010

Journal of Athletic Training

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Context: Arthrogenic muscle inhibition is an important underlying factor in persistent quadriceps muscle weakness after knee injury or surgery.Objective: To determine the magnitude and prevalence of volitional quadriceps activation deficits after knee injury.Data Sources: Web of Science database. Study Selection: Eligible studies involved human participants and measured quadriceps activation using either twitch interpolation or burst superimposition on patients with knee injuries or surgeries such as anterior cruciate ligament deficiency (ACLd), anterior cruciate ligament reconstruction (ACLr), and anterior knee pain (AKP).Data Extraction: Means, measures of variability, and prevalence of quadriceps activation (QA) failure (,95%) were recorded for experiments involving ACLd (10), ACLr (5), and AKP (3).Data Synthesis: A total of 21 data sets from 18 studies were initially identified. Data from 3 studies (1 paper reporting data for both ACLd and ACLr, 1 on AKP, and the postarthroscopy paper) were excluded from the primary analyses because only graphical data were reported. Of the remaining 17 data sets (from 15 studies), weighted mean QA in 352 ACLd patients was 87.3% on the involved side, 89.1% on the uninvolved side, and 91% in control participants. The QA failure prevalence ranged from 0% to 100%. Weighted mean QA in 99 total ACLr patients was 89.2% on the involved side, 84% on the uninvolved side, and 98.5% for the control group, with prevalence ranging from 0% to 71%. Thirty-eight patients with AKP averaged 78.6% on the involved side and 77.7% on the contralateral side. Bilateral QA failure was commonly reported in patients.Conclusions: Quadriceps activation failure is common in patients with ACLd, ACLr, and AKP and is often observed bilaterally.

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“…Alterations in neuromuscular control may influence clinical outcomes. 75,149 Knee surgery results in proprioceptive deficits that should be addressed at the earliest postoperative opportunity. 69 Proprioceptive training can be initiated in the early phase of rehabilitation within the patient's weight-bearing restrictions.…”

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confidence: 99%